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Four hour A&E target –arbitrary goal, or force for good?

Published 15 July 2015

Over the winter and spring months there has been a flurry of media reports about the pressures that A&E services are facing. The NHS failed to meet the target of 95 per cent of patients waiting four hours or less in A&E departments between September 2014 and June 2015.

Verita has recently been asked by a number of NHS trusts to investigate reporting of the four hour target – to assess whether misreporting is occurring and what cultural factors are impacting on reporting behaviour. We found that some patients were being clicked off the A&E system before they had left the department and that for others the clock was being wound back. Essentially we found that attempts to meet the target were resulting in perverse behaviours that were not always in the patients’ best interest.

Sir Bruce Keogh announced on 4 June 2015 that the four hour A&E target should be retained. However the urgent and emergency care review that he undertook with Keith Willett, NHS England director for acute episodes of care, has suggested that there should be a wider range of measures in order to improve outcomes across the system.

This got me thinking about the nature of the four hour target and its suitability as a performance measure for A&E departments. On the one hand it is universally acknowledged that waiting times have significantly reduced since the introduction of the target in 2000 and that this is no bad thing.

However, on the other hand many believe that the four hour target is a nationally derived arbitrary indicator with no clinical basis.

As a patient I would not expect to wait four hours if I needed a wound dressed but on the other hand if there was something seriously wrong I would rather go home after six hours than be admitted in order to avoid a breach.

Even if we agree that timeliness is the most important factor there have been studies that show that performance against the four hours target has no relationship to the median time that patients spend in a department.

Measuring performance solely on the amount of time patients spend in A&E seems to miss the point. What do patients actually value? Surely the most important thing is giving the patient medical reassurance and solving their problem.

The link between four hour performance and mortality rates is not clear. For example Northumbria Healthcare NHS Foundation Trust was on Doctor Foster’s list of 13 trusts with higher than expected mortality rates (December 2013) but is also one of the trusts that met or exceeded the 95 per cent A&E targets in all quarters in 2011-2014. Conversely North West London Hopsitals NHS Trust, which failed in all 12 quarters, had one of the lowest hospital standardised mortality ratios and hospital level mortality indicator rates in the country.

A&E departments are expected to achieve the four hour target regardless of external factors – such as the number of patients attending an A&E and the number of available beds. If there are no beds available, the A&E can do everything right but lack of capacity means the clock ticks on. We can go even further and think about the failure of A&E’s to meet the four hour target as a symptom of whole health system failure. If older people cannot be discharged because care homes are full or mental health patients have to remain in hospital for 12 hours while waiting for a mental health assessment is that an A&E failure?

Going back to our recent investigations, if the A&E arbitrary target for transferring patients to a ward is four hours, but the existing capability is only five, then under pressure, staff may resort to gaming the system.

I am not saying that timeliness of care is not important – being treated faster is better so long as the care received is safe and appropriate. But given the poor performance of A&E departments this year and what we have found about tendencies to game the system, it seems conceivable that the problems are more widespread.

Keogh’s national urgent and emergency care review is looking at the best ways of tracking patient experience and overall performance of the urgent care system. Introducing quality indicators to sit alongside the four hour target seems eminently sensible but I would argue that the review should be extended to examine the extent of ‘gaming’ in the system and should consider again whether the four hour target remains the best indicator of A&E performance.